ORIGINAL ARTICLES
Managerial communication in hospital nursing: obstacles and how to overcome them
José Luís Guedes dos Santos1, Adelina Giacomelli Prochnow2, Dalva Cezar da Silva2, Sonia da Silva Reis Cassettari1, Soeli Teresinha Guerra2, Alacoque Lorenzini Erdmann1
1Federal University of Santa Catarina
2Federal University of Santa Maria
ABSTRACT
Aim: understanding communication difficulties facing nurses in their general duties in a hospital context and the strategies used to overcome these difficulties. Method: a descriptive study using a qualitative approach which included 19 nurses from a university hospital, using a vignette and semi-structured interviews for collecting data, and thematic analysis as the technique for data analysis. Results: the participants considered that the main difficulties were: fragmentation of work processes; work shifts; resistance to change and work team involvement. In the light of these problems, a number of workshops and training programs were held covering topics such as communication, formalization of actions/conduct, and optimization of written/verbal communication. Conclusion: the study shows the nurses’ need to improve their managerial communication skills by understanding the importance of interpersonal relationship and skills in dealing with people.
Keywords: Management; Nursing Supervision; Hospital Nursing.
INTRODUCTION
Management is an important dimension of professional nursing and requires an ongoing search for the development of skills, knowledge and aptitude in order to develop managerial activities in a proactive, efficient and effective way, keeping sight of the quality offered to the users of the healthcare system(1). Among these skills, communication stands out, since increasingly, nurses take a leading role in the management of personnel, teams and the direct or indirect processes directly and/or indirectly related to patient treatment. This position includes the evaluation and implementation of organizational changes and coordination, as well as the supervision and articulation of activities carried out by different professionals in a hospital context(2).
Communication is the process of sharing information, thoughts and ideas with other individuals. For it to be complete, a complex process that is divided into six elements is necessary: source, sender, message, channel, decoder, and receiver. The source can be one or more persons intending to communicate, who create and encode the information to be exchanged, expressed in some form of message and transmitted through a channel to the receiver. To respond to the message and complete the communication, the receiver needs a set of sensorial abilities: the decoder, which converts the message back into information. This is how a message sent out by one person is understood by one or more individuals(3, 4).
In terms of the scope of an organization, the main aim of communication is to foster changes in the attitude, knowledge, or behavior of one or more receivers. In order for the message to be received with the expected impact and to create the desired effect, it must be understood. That is why the codification process, that is, the translation of an idea or thought into meaningful symbols, is so important. The message may include spoken/written words, as well as non-verbal communication, such as gestures, facial expressions and posture. The communication channels can be face-to face meetings, emails, letters or written reports, etc. The choice of the communication channel should be made based on the aim of the message and the ability of the sender/receiver to use it (4).
The communication process is only complete when the message is received, interpreted and creates a result. In many cases, the interpretation of the message by the receiver can be very different from the intended meaning of the sender. Decoding can be potentially impaired by several factors, including the knowledge and experience of the receiver and his/her relationship with the sender, the absence of feedback, cultural differences, and the effects of status. In addition, the social context in which the message is received can also make a difference(4).
In nursing management, studies have highlighted that the effectiveness of communication can be hampered by conflicts in interpersonal relationships, the centralization of decision-making processes and distortion of the information flow(5, 6, 7).
Communication failure and difficult conversations are inevitable in interactive processes, especially when one holds a managerial position in which it is necessary to lead a group of people, defend and uphold a viewpoint, hold a dialogue, or censure someone for a mistake. Consequently, it is important to develop strategies and tactics that make these situations less stressful, and avoid the intensification of any problems and deterioration of work relationships(8). Consequently, in order to offer a basis that can contribute to the efficiency and effectiveness of the communication process in nursing management, a question is raised: what are the communication problems of nurses in their management role in a hospital context? What are their own suggestions for strategies to overcome these problems? Thus, the aim of this study is to identify and understand the communication difficulties facing nurses in their management role in the hospital context, and to identify the strategies they suggest to overcome these difficulties.
METHODOLOGY
This is an exploratory-descriptive study using a qualitative approach. The setting for this research is a university hospital in the state of Rio Grande do Sul. At the time of the research, this organization was made up of a consultative body, the Administration Counsel and an Executive Board - a normative entity, involving the General Board, the Clinical Board, the Administrative Board, the Nursing Board, and the Board of Education, Research and Extensions. The Nursing Board covers 5 coordination departments: maternal and child department, medical clinic, surgery, ambulatory nursing, and psychiatric nursing. Each of these coordination departments provides services specific to their areas such as internment units, intensive therapy, and emergency and ambulatory treatment. Thus, the institute had 5 area coordinators and 20 heads of service.
The area coordinators are nurses who work 8 hour daily shifts, besides hours on standby, to complete the weekly workload, except for Saturdays and Sundays, when they have time off. The nurses responsible for the service units – nurse managers or heads of units – work as nurse manager and assistants, simultaneously carrying out corresponding activities. Most of the managers work during the morning shift, although at times they work in the afternoon or at night according to hospital needs or personal choice.
The research participants included 19 nurse managers (3 area coordinators and 16 chief nurses). This sample was intentionally chosen between head nurses and area coordinators based on the criteria of data saturation. Any nurses on vacation or on leave were not involved in the research.
The data was collected using vignette techniques and semi-structured interviews. The vignette was based on a hypothetical situation that described the “ideal” communication process for work, management and nursing in a hospital environment, prompting the nurses to give their opinion on the factors that hindered “ideal” communication in their management routine.
In the semi-structured interview, data was initially gathered regarding the socio-professional characterization of issues such as age; sex; nursing experience; period of time working for the institute; period of time working at their present position; academic credentials and participation in management courses.
After this, answers were considered for the following questions: What communication difficulties do you face in your management routine? Which strategies do you suggest to overcome these difficulties? The interviews lasted between 20 and 30 minutes, and were held at a time and place previously scheduled by the participants. The interviews were recorded and later transcribed.
The collected data was analyzed using a technique of thematic content analysis which is made up of 3 stages: ordination, data classification and final analysis. In the ordination stage, the data gathered was typed out using the vignettes and interviews, re-reading of the material and ordination of the reports. In the data classification stage, the association between collected data and theoretical references was made by extensive and repetitive reading of the transcripts, in order to identify the relevant points. In the final analysis stage, the empirical and theoretical material was articulated accordingly to interpret and obtain the abstraction of the underlying content of what was expressed(9).
The project was approved by the Ethics Committee of Santa Maria University (Process nº 23081.010121/2007-97). The research participants received all the necessary information and signed a Term of Willing and Clarified Consent, thus formalizing their consent to participate, in compliance with Resolution nº 196/96 of the National Health Counsel. Their identities were disguised by means of code numbers for the identification of their interviews (D1, D2… D19).
RESULTS
Of the 19 study participants, all were women aged 31 to 69, with a minimum of 6 years of experience, while 10 of them had 20 to 30 years of experience and had been working professionally in the institute for at least 15 years. As for experience in their present position, 11 of them had less than 1 year’s experience; only 4 did not have any previous management experience.
As far as professional training was concerned, 16 nurses had a Post-Graduate degree; 2 had a Master’s degree in nursing and the rest were specialists, 6 of whom were specialized in healthcare services management. In addition, 11 managers stated that they had undertaken specific management courses that covered communication skills.
Based on the interviews of the nurse managers, 2 topics were analyzed:
Each of these topics resulted in 3 categories as indicated below:
Topic 1 - Communication problems of nurse managers in a hospital context
Category 1.1: Fragmentation of work processes
The fragmentation of work processes in terms of services provided/units in the institute, was the main problem reported by the nurses, since it hindered the interaction between the staff and teamwork.
“[...] there are a lot of fragmented tasks. At times, we want to work something out, but I don´t work alone, I work in a team, I need to communicate, I need to talk to people and tell them what I’m thinking [...]” (D1)
“[...] we work in a very individualized policy. I am a doctor, I write prescriptions, the nurse performs the treatment, and there is a lack of communication, each of us does what we think is right. Why don’t we get together to talk and decide on the treatment and conduct? Some criticize the others and are not capable of discussing issues and having a dialogue.” (D4)
Category 1.2: Work shifts
The organization of nurse work into shifts was mentioned as a problem, since the nurse managers worked in the morning/afternoon shifts. As a result, there was no direct contact with the night shift staff at times, and consequently the communication was very indirect, usually being messages given by others or by phone, which could hinder the comprehension of the original message sent by the nurse manager:
“ to get in contact with the night shift staff, you need to make a real effort. You need to stay until the evening, 3 shifts in a row, to contact them, because if I just leave a message, I am not sure they will receive it” (D8)
“[...] the fact is that it´s a 24 hour situation, and so there are people I never even meet, and the message you leave isn’t always passed on, there are distortions[...]” (D12)
Category 1.3: Resistance to change and involvement of the work team
The nurse managers mentioned that certain individual characteristics of the people they interact with in their management routine hinder communication, such as resistance to change and the involvement of the work team with the institute.
“[...] you have to get people together to explain something important, and when you look for someone and they can’t talk at the moment, or someone doesn´t show up, you have to run around looking for people and so it is quite demanding” (D1)
“Sometimes it’s the people who don’t get involved with the job; there is a lack of interest” (D7)
“[...] we manage a group and this group can be very diverse, and depending on who you are talking to, communication can become very difficult or simply not happen. So whenever we want to introduce something new there is usually a lot of resistance (D16)”
Topic 2 – Strategies for the improvement of communication skills for nursing management in a hospital context
Category 2.1: Workshops and training programs
Workshops and training programs were pointed to as a strategy to raise awareness of the importance of communication for nurses and hospital staff:
“Reflection groups, workshops [...] with dynamic activities so that the whole group can come out late thinking about the issue, you understand? What can change here? I think that is how changes start. So, it has to be a course aimed at reflection and not that formal kind of class” (D10)
“[...] I really think it would have to be done through training, through observation, so that it could be the same for everyone” (D13)
Some of the research participants pointed out the importance of management communication training for themselves, as nurses in a management role:
“[...] perhaps we as managers need it ourselves, some kind of training to use other methods, because each person has his/her own preferred way of understanding: verbally, written etc.”(D1)
“We know we have to invest more in management courses, in postures. You have to know how to manage; the technician does his own job. Delegate more, without neglecting your own responsibilities, be less task-oriented and take a more managerial stance. (We need to) Participate in a course or workshop to get the necessary skills for this”(D11)
Category 2.2: Formalization of actions and conduct.
The formalization of actions and conduct by written records was pointed out as a proper strategy to ensure continuity and consistency of the actions between hospital services/units and consistency in the interpretation of the decisions made:
“Things can´t be so informal. Whatever is important has to be formalized and written records must be used so that things flow and run better” (D8)
“There should be an internal communication system, using memos, notices, I don´t know. There is a real need to formalize communication”(D17)
Category 2.3: Optimization of written and verbal communication.
In order to optimize verbal communication, the nurses suggested the use of verbal communication, that is, they opted for direct communication, face-to-face. As per written communication, they highlighted the strategy of placing post-its/written announcements in places that would be easy to see, like on the fridge door of the staff canteen.
“As far as passing on information is concerned, I prefer face-to-face conversations. People don’t read post-its, they don’t open emails, so I go up to them and give the message directly” (D2)
“[...] I communicate in a place everyone has easy access to and it’s not on a wall, it’s on the fridge door” (D18)
DISCUSSION
The group of nurses that was involved in the research was characterized by a relative life experience background, professional maturity, and who work with nursing management in a hospital context. Based on their interviews, it became evident that managerial communication, as a complex process that involves least 2 people meeting to exchange information, is not always successful. In other words, it does not always achieve the desired outcome. Most of the time, other intervening factors in the management process associated with being a nurse comes first in the list of priorities, relegating communication to a supporting role in the person’s decision-making. As a result, conditions are not always suitable for communicating or even understanding a message.
The fragmentation of work processes in the hospital was the main problem mentioned by the nurse managers. This problem may be related to the limited amount of collective space available for planning, discussing and evaluating the tasks carried out in the work environment. Consequently, most of the time, each healthcare professional performs his/her activities in an isolated way, focusing on his/her own knowledge, thus hindering teamwork and an effective communication process.
In addition, the different status and hierarchical levels occupied by healthcare professionals in a hospital context can hinder communication and interactive processes, as described by a study in which the separation of nursing services in hierarchical levels appears as a factor that negatively affects communication processes in a hospital context(6).
Another problem mentioned by the participants in the study was the organization of the nurses’ work into shifts. Since both Nursing Department Heads and Coordinators work in the morning/afternoon shifts, they would not always meet with the night shift staff, and communication was usually through phone calls or messages passed on by others. When communication is processed through messages or notes left on bulletin boards, the process becomes indirect, which can hinder the reliability of the message and the desired outcome when this transfer is done indirectly. Therefore, the nurse manager needs to develop ways to mobilize people, promote a healthier working environment, and still be capable of dealing with contradictions and disorder in order to establish a new order(2).
It is important to understand that by taking up a post at any level of a hierarchical organizational structure (direction, coordination, leadership or management), the nurse must leave behind almost all of the baggage acquired until then, especially when it imposes boundary limits where there is a concentration of interests from restricted groups and these are well defined. One must begin to master institutional macropolitics and be able to place oneself therein to comprehend the rhizomatic chain that needs to be created in order to succeed in the work process. With this, possible and consistent advances can settle the feeling of failure that is almost ubiquitously expressed by nurses in a leading role.
Resistance to change and work team involvement were also pointed out by nurse managers as the problems that hinder the quality of the communication process. Resistance to change may represent a shortcoming in the communication process itself, in that no team awareness was raised, or even as a result of imposed decisions.
In this sense, some questions may result from the interviews undertaken as part of this study: does the current work relationship model in public service reflect the notion that civil servants can do anything, and are allowed to anything they please? Does the large number of demands made by the nurse managers, eager for perfection, make it difficult for them to see the advances made, however subtly, in their teams? Is the organizational structure insensitive to the calls for change, demonstrated many times by the low level of commitment to its rules, norms and current routines?
It is important for a manager to assign responsibilities to his/her team in a way that the members of the team can naturally commit themselves as a whole to the well-being of the organization and to the service it offers(10). The moment the communication process accomplishes its stages and reaches all of its components/members, the lack of commitment will partly decrease, which then allows the nurse manager to intervene and suggest changes in attitude so that new values can impact on the daily routine.
As a result, changes can be made to systems bound by old traditions which hamper the advances that are so essential to professional nursing. Organizations frequently emphasize what they call “corporate values”, molded by the personality of their founders, directors or managers. However, it is difficult to apply them in terms of real values. Values are individual principles that substantiate concepts of good and bad, right and wrong, which are modified very slowly when change. In the context of an organization, no matter how clear and objective these values are stated, they can become difficult to understand and apply. Thus, to promote inclusion, coherence and commitment, it is more useful to consider sharing practices and work procedures instead of values. People are much more willing to embrace common practices than values(10). When asked to consider strategies that could improve and enhance management communication in a hospital context, the participants of this study highlighted the importance of communication training and workshops to stimulate the involvement of people in terms of their jobs and the commitment to the activities they carry out, as they would have a better view of their role and how their job is interrelated to the other aspects of the institute. The management courses suggested is a key strategy since, quite frequently, nurses who hold management positions do not have specific training for this. Consequently, the activities suggested by the nurse managers could result in a better understanding of the needs of the institute and their colleagues, as well as helping them in decision-making.
Research on the part of specialists in communication and nursing, states that in order to have efficient communication, it is essential to have technical training and interpersonal skills in order to learn to listen and understand the other person. This then requires basic communication skills, awareness of what is verbal and non-verbal during interactions, clarity and objectiveness. Another attribute of successful communication in nursing is respect for the other person, bearing in mind that emotions, expectations and stereotypes all interfere with communication, as well as any previous encounters between those involved(5).
The formalization of actions and behavior was outlined as a strategy for ensuring consistency and continuity of actions between services and staff. This strategy is understandable given the amount of information involved in management and treatment procedures in a hospital context. Nonetheless, it is necessary to reflect on to what extent communication can be formalized, as suggested by the research participants. In institutional terms, there are issues that can and must be informed and, whenever necessary, written and registered formally. As for communication, this is understood as a dialogical and interactive relationship between 2 or more people, and is an important moment of social interaction in the workplace. It requires proximity and the establishment of a relationship among the staff, which does not happen when formal communication is used.
This strategy may be related to how nurses have problems dealing directly with conflict during work(7), and the influence of the dimension of technical and administrative bureaucracy in nurse management(2). In many cases, people feel uncomfortable wielding power themselves, and prefer some kind of impersonal rule that helps them in decision-making. Unfortunately, rules do not have discretion and discernment. That is why they do not adapt properly to dynamic and complex environments such as hospitals. An alternative is cultivating a responsible attitude, through which people strive for the well-being of the organization as a whole – which in turn increases its control. People behave naturally according to their attitudes, so these shouldn´t be bypassed. If a rule is more important than a responsibility, people will follow blindly, even when their actions defeat the purpose(10).
Another important feature is the strategy suggested by the research participants to optimize written and verbal communication. The suggestion of using “face-to-face” communication highlights the importance of the nurse manager taking a more dialogical stance, in which communication is used to listen to and understand the other person, so ideas can be exchanged.
As regards the channels used in written communication, for which the nurses mentioned placing stickers/post-its on the fridge door in the staff canteen, there is a visible need for technological resources like access to Internet and for emails to be used more efficiently by the nurse manager in the workplace, since it’s the fastest and most effective form of communication. The use of email/groups/social networks is difficult in nurse management since not all the hospital sectors have structural conditions that offer easy access to computers, and many nurses simply don´t know how to use these communication tools(6).
Overcoming these obstacles is important to strengthen the communication processes in organizations by using communication technology more effectively, and aiming to select and combine technologies to fully benefit from them (10). Consequently, there is clearly a need for better training so that the employee can use this technology, whether from courses offered by the institute or in terms of his/her own choice of external training.
CONCLUSION
The research considered the main problems for managerial communication in hospital nursing as being related to the following categories: work processes fragmentation; work in shifts; resistance to changes; and staff involvement.
To overcome these problems, the study participants’ suggestions according to the categories above were communication training and workshops, the formalization of actions and conduct and the optimization of verbal and written communication.
This study shows the need for nurses to improve their skills in managerial communication through a more theoretical understanding of the elements of the communication process, as well as the importance of interpersonal relationships and the development of people skills for successful managerial communication in hospital nursing.
Communication in nurse management cannot be learned using a prescriptive, normative or explanatory model which is strictly followed, as it is a peculiar and single process that results from multiple and complex relationships, interactions and associations among people that are related to a specific context.
This research offers a basis for nurse managers to reflect on their communication methods and to develop strategies to improve them according to the characteristics of the institute or healthcare service they work in. In addition, the research highlights the importance of academic training for nursing management that gives students a greater number of opportunities to develop skills such as leadership, communication, social interaction and decision-making processes throughout the entire training program.
The importance of these skills is discussed with student nurses, usually during the last semesters of academic training in courses such as management/administration of nursing and healthcare. Nevertheless, they should participate in all the assisting activities developed in the other courses in order to bring attentiveness and management into the routine of nursing in a hospital context.
In future research, it is recommended that technicians and nurse assistants be interviewed and asked to give suggestions for the improvement of communication in nursing management, since they play a key role in the workforce of the profession and are the main people with whom a nurse interrelates as part of their managerial duties.
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Contribution of authors: Conception and design: all; Analysis and interpretation: all; Article Writing: all; Critical revision of the article: Adelina Prochnow Giacomelli; Final approval of the article: Alacoque Lorenzini Erdmann; Collecting data: José Luís Guedes dos Santos; administrative support, logistical and technical: José Luis Guedes dos Santos.
Received: 04/02/2012
Approved: 01/08/2012